INDIVIDUAL MEDICAL INSURANCE

Transcription

1 INDIVIDUAL MEDICAL INSURANCE

2 ABOUT JUBILEE Jubilee Insurance was incorporated on 3rd August 1937, in a small office in Mombasa and is one of the pioneers in the establishment of a local composite insurance company. In keeping with our mission of contributing to the economic growth of the region, Jubilee Insurance took the bold step of converting itself into a public Company in 1984, to broaden its ownership base locally which now consists of over 5,000 shareholders. Today more than seventy five since inception Jubilee Insurance is a leading insurance company in East Africa with the largest shareholders funds and solid emphasis on security for policyholders, information technology, committed, knowledgeable & professional staff, and a reputation for superior customer service. Currently, the Jubilee Insurance group is the largest medical insurance underwriter in East Africa. KEY BENEFITS 1. 5 Levels of Comprehensive cover with optional benefits (Maternity, Outpatient, and Optical). Select the plan and options to suit your medical insurance needs and budget 2. Cover for Pre-Existing, Chronic, Psychiatric, congenital and HIV/AIDS including related conditions 3. Country wide Provider Network 4. Overseas inpatient referrals covered on credit under listed hospitals 5. Cover for inpatient dental and optical treatment 6. Post hospitalisation benefit 7. Funeral expenses benefit 8. Free Personal Accident benefit for Principle member 9. Direct access to treatment within East Africa PLAN SUMMARY J-CARE INDIVIDUAL/FAMILY MEDICAL INSURANCE INPATIENT BENEFITS (CORE PRODUCT - COMPULSORY) All inpatient treatment is subject to pre authorisation All benefits are subject to overall annual benefit unless specified otherwise PLANS CLASSIC PREMIER ADVANCED EXECUTIVE ROYAL Overall benefit limits in KShs. per insured family per annum 500,000 1,000,000 2,000,000 3,000,000 5,000,000 Pre -existing, Chronic, Congenital Conditions, HIV/ AIDS and related conditions existing/not existing and/ or not diagnosed at the time of joining. Subject to full disclosure at the time of joining (1 year waiting period) 250, , , ,000 1,000,000 Cancer treatment (2 waiting period) Organ Transplant (1 year waiting period) Psychiatric conditions (1 year waiting period) 100, , , , ,000 Bed limits per day net of NHIF Lodger Fees for parent accompanying sick child member General Ward Bed General Ward Bed General Ward Bed Standard Private room up to KShs.12,500 Net of NHIF Standard Private room up to KShs.18,000 Net of NHIF 1.

3 Physicians, specialists, surgical fees including anaesthetist fees, theatre charges, HDU, CCU & ICU, Diagnostic Tests, physiotherapy as part of inpatient treatment Inpatient MRI/CT Scans and PET Scans (authorisation required) Surgical appliances/internal prosthesis Reconstructive surgery following an accident Inpatient non accident related dental surgery/treatment (1 year waiting period) 100, , , , ,000 Inpatient dental surgery from an accident Inpatient opthalmology surgery as a result of an accident Inpatient non accident related eye treatment (excluding correction of refractive errors and laser treatment) (1 year waiting period) 100, , , , ,000 Day case surgery under general anaesthesia Medically necessary home nursing on doctor s recommendation from hospital Post hospitalisation treatment Discharge take home medication OTHER BENEFITS INCLUDED WITHIN INPATIENT COVER 90 days 90 days 90 days 90 days 90 days Max 10,000 Max 15,000 Max 20,000 Max 25,000 Max 30,000 Local road ambulance to hospital for emergency cases Covered Covered Covered Covered Covered Commercial Air Evacuation out of Kenya (must be pre authorised) for treatment not available or not safe to undertake locally Funeral expenses - (free for principal member. Optional for dependant over 18 yrs.) Personal Accident (Free for Principal Member. Optional for dependents over 18 yrs.) OUTPATIENT BENEFITS (OPTIONAL) Not applicable Not applicable Economy return fare only within Africa, India and Pakistan Economy return fare only within Africa, India and Pakistan Economy return fare only within Africa, India and Pakistan 50,000 50,000 75, , , , , , , ,000 Annual limits 50,000 50,000 80, , ,000 Consultation fees (doctors on panel) Pathology, Xrays, MRI, CT Scan and other necessary diagnostic tests *1 Prescription drugs and dressings upto a maximum of 30 days dosage Gynacological illness and treatment*2 2.

4 Pre-existing, chronic cover, Psychiatric, Congenital conditions and HIV/AIDS and related treatment ( 1 year waiting period) Cancer treatment (2 year waiting period) Physiotherapy (pre authorisation required) ROUTINE MATERNITY BENEFITS (OPTIONAL) Annual limit per member/spouse 80, , , , ,000 KEPI Vaccinations (within maternity limit and subject to pre-authorisation) Pre-natal & Ante-natal outpatient treatment ( 1 year waiting period) Benefits covered under maternity limit (1 year waiting period) ROUTINE DENTAL BENEFITS (OPTIONAL)* up to 5,000 up to 5,000 up to 5,000 up to 5,000 up to 5,000 Covered under maternity limit Normal and C-Section delivery. Labour/recovery ward, professional fees, pregnancy/ maternity related hospitalisation, other related ailments & complications including etopic pregnancy and miscarriage Annual Limit per person 5,000 10,000 20,000 30,000 40,000 Benefits covered (pre-authorisation required) ROUTINE OPTICAL BENEFITS (OPTIONAL)* Fillings, Fillings, Fillings, Fillings, Fillings, Annual Limit per person 5,000 10,000 20,000 30,000 40,000 Benefits covered (pre-authorisation required) lenses every 2 This is only a summary of the benefits for more details refer to the policy document * and Optical options are available only with Outpatient plans. lenses every 2 lenses. Frames limit - KShs. 10,000/- every 2 lenses. Frames limit - KShs. 10,000/- every 2 lenses. Frames limit - KShs. 10,000/- every 2 3.

5 GENERAL CONDITIONS 1. General waiting period of 30 days for new entrants on illness claims. No waiting period for accident related treatment. 2. *(1) MRI, CT scan on pre authorisation. 3. *(2) Fibroids, Adenoidectomy, Haemorrhoidectomy and Tonsillectomy procedures shall have a waiting period of 1 year. 4. Cancer treatment will be subject to 2 waiting period. 5. Pre-existing, Chronic, Psychiatric, Congenital, Organ Transplant, HIV/Aids and related treatment, Maternity and related complications, inpatient non accident related ophthalmology and dental surgery shall be subject to 1 year waiting period. 6. Eligible for the main member and his/her legal dependents from the age of 1 month to 60. Existing members can continue on cover up to age of 65. Children above 18 will enjoy their own cover as principle members. 7. New applicants aged 50 and over will be required to undergo a medical examination at specific providers, before membership and eligibility of cover can be confirmed. Please note that this will be at applicants cost. 8. Cover must be confirmed in writing and premiums paid to Jubilee Insurance for the benefits to be effective. 9. All scheduled admissions must be pre authorised at least 48 hours prior to admission. 10. For emergency admission the hospital will contact Jubilee Insurance within 48 hours of admission. 11. All inpatient hospital bills shall be paid net of National Hospital Insurance Fund (NHIF) 12. Medical cards must be presented at the accredited panel of providers for access to service. Each member will also be required to complete and sign a claim form. 13. A member travelling outside the country will be eligible for emergency medical benefits up to a period of six (6) weeks in any one visit. All medical expenses will be on reimbursement basis and will be within the acceptable guidelines of the Kenyan Medical Practitioners and Dentists Board and as per the policy terms and conditions. 4.

6 EXCLUSIONS 1. Treatment for pre-existing chronic conditions, congenital and psychiatric conditions (within the first year) 2. Treatment for HIV/AIDS and related ailments (within the first year) 3. Treatment of Cancer (within the first two ) 4. Sexually transmitted diseases except HIV/AIDS 5. Peri-Menopause, Menopause, andro-pause,hormone replacement therapy, age and puberty related treatment Organ transplant (within the first year) 6. Treatment of Haemorrhoids, Fibroids, Hernia (except congenital), Adenoidectomy (within the first year). 7. Genetic disorders and related conditions. 8. Cosmetic or plastic surgery unless necessitated by an accidental injury that occurs while the insured is covered under this contract; 9. Riding or driving in any kind of race 10. Beauty treatment or massage 11. Naval, military and air force operations 12. Stays at sanatoria, old age homes, places of rest etc. 13. Medical check-up, general health examinations, prophylactic treatment, vaccinations except for KEPI vaccinations. 14. Transportation other than a licensed ambulance, as provided for under the in-patient coverage of this contract 15. Hearing tests or cost of hearing aids unless resulting from an accidental injury 16. Nutritional food supplements or replacements. 17. Injury or illness resulting from insurrection or war, civil commotion or an act of terrorism, whether declared or undeclared 18. Injury as a result of participating in riot, strike 19. Alternative treatment such as herbal treatment, acupuncture treatment, chiropractors etc. 20. Expenses resulting from the insured participating in extreme/hazardous sports and activities 21. Pain management 22. treatment including teeth extractions, fillings, teeth scaling, etc. unless the dental cover has been purchased. 23. Optical treatment relating to correction of eyesight e.g. eye glasses, contact lenses, laser eye treatment unless the optical cover has been purchased. 24. ntentional self-injury while sane or insane, suicide or attempted suicide, treatment of acute or chronic alcoholism and drug addiction 25. Expenses recoverable under any other insurance e.g. NHIF 26. Treatment required as a result of noncompliance, failure or refusal to comply with medical advice 27. Pregnancy, childbirth, maternity benefits, medically necessary abortion, miscarriage, antenatal or postnatal care, caesarean operation except where purchased and subject to twelve months waiting period 28. Contraceptive services and supplies, family planning and fertility treatment e.g. costs of treatment related to infertility and impotence, any injury, illness or disease specified as exclusion and complications caused by a condition that is excluded. 29. Services primarily for weight reduction or treatment of obesity and slimming preparations or any care which involves weight reduction as a main method of treatment. 30. Epidemics, pandemics or unknown diseases PROVIDER PANEL Jubilee Insurance s provider panel allows members access to the medical care they require. The panel is on credit basis, which means that provided the treatment is covered and has been pre authorised where necessary, the bill will be settled directly with the service provider. This allows members to get quality care when required. The provider panel will be in the membership pack upon purchase of the policy and the same can also be accessed via the Jubilee Insurance website APPLYING FOR COVER To apply for cover, complete and sign the member application form. Submit it together with the required supporting documents. Jubilee Insurance shall revert within 3 working days of receipt of your application and confirm the terms and conditions applicable. 5.

7 The policy will be effective from the date the premium is paid. Waiting periods where applicable will start from the date the policy is effective. POLICY DOCUMENTS Once the policy commences, you will receive a membership pack within 30 days which will include:- Membership Card (s) Welcome Letter confirming the plan and benefits purchased Policy document List of providers FREQUENTLY ASKED QUESTIONS When does my cover commence? The cover commences once Jubilee Insurance provides you with an acceptance letter and once premium is fully paid. To whom should premiums be paid to once I have received confirmation that my application has been accepted? Payment should be made directly to Jubilee Insurance by the following means: Cheque MPESA Number Cash payment to our Head office or any of our branches What am I covered for? The benefit options are provided in this brochure and the further details will also be provided in the policy document Which hospitals can I go to? A list of providers and specialists will be provided in your membership pack. The same can be accessed on the Jubilee Insurance website. You can also call our offices directly for further assistance. What do I need in order to access a credit facility? Remember to always carry your Jubilee Insurance medical card and your national ID/ Passport in case further verification is required. What is the procedure of enrolling a new born child? Inform Jubilee Insurance immediately the child is born and provide all documentation (application form and passport size photo) as soon as possible. Cover commences once Jubilee Insurance confirms acceptance and full premium is paid. What does the policy say about treatment abroad? A member is covered whilst temporarily abroad and requiring emergency treatment for an illness or injury that occurs during the period of travel provided that such period does not exceed six weeks in any one visit and will be covered on reimbursement. Travel and accommodation costs are not covered. How do I change my policy if I am covered with another Insurer? Provided there is no break in cover, and subject to the underwriting procedures some of the waiting periods may be waived allowing for a seamless transition. Once I have the initial medical examination having joined after the age of 50, will I need to go for an examination at each renewal? Jubilee Insurance may require medical examination when necessary. Communication will be provided in writing at the policy renewal. 6.

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